Sundheds- og Forebyggelsesudvalget 2012-13
KOM (2012) 0788 Spørgsmål 16
Offentligt
TO:  Astrid  Krag  
Minister  for  Health  
Holbergsgade  6  
DK-­‐1057  Copenhagen  K  
sum@sum.dk  
 
CC:  Europaudvalget  
Mrs  Eva  Kjer  Hansen  
eva.kjer.hansen@ft.dk  
 
CC:  Sundheds-­‐  og  Forebyggelsesudvalget  
Mrs  Sophie  Hæstorp  Andersen  
sophie.andersen@ft.dk  
 
From:  
Professor  Martin  Jarvis  
Professor  Karl  Olov  Fagerström  
Professor  Michael  Kunze  
Dr  Karl  Erik  Lund  
Dr  Jacques  Le  Houezec  
Dr  Tony  Axell  
Dr  Lars  Ramström  
Mr  Clive  Bates    
 
17  June  2013  
Dear  Mrs  Krag,  
 
Re:  Tobacco  Products  Directive  and  snus  –  Denmark’s  potential  role  
We  are  writing  to  you  as  independent  public  health  specialists  as  the  Tobacco  Products  Directive  
continues  its  passage  through  the  European  Parliament  and  Council.  We  write  to  express  our  hope  
that  you  personally  will  take  a  positive  approach  to  oral  tobacco  (‘snus’)  in  forthcoming  discussions  
in  the  European  Health  Council.    We  were  greatly  encouraged  by  the  reasoned  opinion  of  Denmark’s  
parliament  and  hope  that  Denmark  will  play  a  positive  role  in  overturning  more  than  two  decades  of  
the  highly  counterproductive  ban  on  snus  throughout  the  European  Union  outside  Sweden.  This  
would  be  a  victory  for  public  health,  consumer  rights  and  common  sense.      
 
Health  potential  of  snus  in  Denmark  and  the  rest  of  Europe.  
 There  has  been  a  remarkable  success  
for  public  health  in  Sweden  that  deserves  more  recognition  by  policy-­‐makers  in  other  member  
states.    According  to  the  most  recent  
Eurobarometer  
survey
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,  adult  smoking  prevalence  in  Sweden  is  
just  13%,  half  the  level  of  Denmark  and  far  lower  than  the  EU  average  of  28%.    The  reason  for  this  is  
perfectly  clear:  it  is  that,  in  Sweden,  snus  has  been  widely  used  to  quit  smoking  or  as  an  alternative  
to  cigarettes.    Given  that  the  risks  associated  with  snus  use  are  of  the  order  of  95-­‐99%  lower  than  for  
smoking
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,  this  has  resulted  in  substantially  reduced  burdens  of  tobacco-­‐related  disease  (cancer,  
cardiovascular  disease,  emphysema).  The  rate  of  lung  cancer  mortality  in  Sweden  is  half  that  of  
Denmark  according  to  the  most  recent  figures  available  from  the  World  Health  Organisation
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.  
Sweden  also  has  significantly  lower  levels  oral  cancer  mortality.  
 
The  tobacco  harm  reduction  concept.  
Throughout  Europe  starting  in  the  1960s  there  have  been  
steadily  increasing  efforts  to  reduce  smoking  through  controls  on  marketing  and  branding,  health  
warnings,  taxation,  restrictions  on  smoking  in  public  places,  information  campaigns  and  support  for  
smoking  cessation.    Smoking  rates  have  reduced  considerably,  and  impressively  in  Denmark,  but  
today  more  than  one  in  four  adults  in  Denmark  still  smokes,  and  the  WHO  still  predicts  one  billion  
premature  deaths  from  tobacco  worldwide  in  the  present  century.    The  experience  of  wider  snus  use  
points  the  way  to  a  new  and  additional  strategy  –  tobacco  harm  reduction.    This  means  helping  the  
many  people  who  are  unable  or  unwilling  to  give  up  nicotine  or  tobacco  to  use  it  in  ways  that  cause  
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them  dramatically  reduced  harm.    Snus  and  the  new  nicotine  products,  such  as  e-­‐cigarettes,  meet  
this  important  need  and  there  is  no  case  –  scientifically  or  ethically  -­‐  to  restrict  them  in  the  ways  
envisaged  in  the  proposed  directive.    That  point  was  made  sharply  and  correctly  in  the  Danish  
parliament’s  reasoned  opinion
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:  
 
The  majority  cannot  therefore  support  a  ban  on  the  marketing  of  ’snus’,  regardless  of  how  it  
is  packaged.  The  majority  furthermore  notes  that  ’snus’  is  less  harmful  to  health  than  
conventional  cigarettes  and  does  not  lead  to  passive  smoking”.  
   
 
We  would  like  to  summarise  the  problem  and  propose  a  pragmatic  solution.  
 
Problem.  Under  the  proposed  directive,  snus  would  remain  banned  outside  Sweden  and  smokers  
will  be  denied  options  to  reduce  their  risk  –  this  is  detrimental  to  public  health  in  Denmark  
The  ban  on  oral  tobacco  (outside  Sweden)  has  no  scientific  basis:  
the  evidence  points  to  
significant  
net  health  benefits  
from  snus  use  due  to  reduced  smoking  with  no  evidence  of  
significant  ‘gateway  effects’  or  other  unintended  and  undesirable  consequences;  
It  is  deeply  unethical:  
 in  our  view  it  is  an  abuse  of  authority  to  deny  any  tobacco  or  nicotine  user  
access  to  products  that  may  greatly  reduce  their  individual  risk  –  there  are  many  existing  
potential  snus  users  among  Northern  Europe  citizens  moving  freely  in  the  European  Union;  
There  are  no  precedents:  
we  cannot  identify  any  other  product  where  a  much  less  hazardous  
alternative  (snus)  to  the  dominant  high-­‐risk  product  (cigarettes)  is  banned.  While  cigarettes  are  
widely  available  in  the  EU,  there  can  never  be  a  case  for  banning  a  vastly  safer  alternative;  
The  ban  is  unlawful:  
 both  common  sense  and  professional  legal  opinion  suggest  a  ban  on  an  
arbitrarily  defined  sub-­‐category  of  smokeless  tobacco  is  discriminatory  and  disproportionate  and  
certainly  does  not  contribute  to  a  ‘high  level  of  health  protection’  within  the  single  market;  
There  is  no  internal  market  logic:  
the  ban  protects  the  cigarette  category  from  competition  and  
penalises  businesses  and  employees  that  make  a  significantly  less  damaging  tobacco  product.  
Proposed  solution.  
We  believe  this  is  politically  achievable  and  would  create  a  more  rational  
approach  to  oral  tobacco  /  snus  in  Europe.  
1. Replace  the  ban  with  a  regulatory  framework  for  all  smokeless  tobacco  that  would  limit  the  toxic  
contaminants  that  potentially  cause  harm.  That  approach  is  already  used  voluntarily  for  snus  in  
Sweden  and  Denmark.    This  could  remove  from  the  market  some  of  the  more  dangerous  
smokeless  tobacco  products  that  would  otherwise  remain  on  sale  under  the  proposed  directive.  
The  WHO’s  expert  group  on  smokeless  tobacco  recommended  exactly  this
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,  and  the  approach  is  
supported  by  the  UK  Royal  College  of  Physicians  and  many  experts.  
2. If  a  complete  lifting  of  the  ban  is  politically  impossible,  then  the  decision  to  ban  oral  tobacco  
should  become  a  matter  for  each  member  state  –  reflecting  the  diverse  cultural  traditions  in  
tobacco  use  and  the  different  attitudes  to  harm  reduction.    However,  it  would  use  community  
competence  to  create  harmonised  rules  in  an  effective  single  market  in  those  member  states  
that  decide  to  permit  sales  of  oral  tobacco.    This  would  in  effect  extend  the  concession  made  to  
Sweden  at  its  accession  to  other  EU  member  states  that  wished  to  adopt  it.    It  would  not  require  
it.  Even  those  countries  that  do  not  wish  to  exercise  the  option  now,  may  value  the  right  to  
exercise  it  in  the  future  –  without  requiring  a  new  legislative  proposal.  
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The  draft  directive  as  formulated  will  deny  citizens  in  other  member  states  access  to  a  much  lower  
risk  alternative  to  smoking.  Furthermore,  it  threatens  to  undermine  significant  health  gains  that  
have  been  made  in  Sweden.    There  is  no  scientific,  ethical  or  legal  basis  to  do  this,  and  we  hope  that  
you  will  speak  frankly  and  act  decisively  for  public  health  as  the  directive  completes  its  passage.  We  
realise  this  is  difficult,  and  that  it  can  appear  to  be  supporting  a  tobacco  product.  In  reality,  it  is  
supporting  better  health  and  challenging  the  dominance  of  cigarette  smoking,  which  is  the  most  
harmful  and  addictive  form  of  tobacco  and  nicotine  use.  
If  you  would  like  to  pursue  these  arguments,  we  would  be  pleased  to  provide  you  with  more  
detailed  information.  If  you  would  find  it  useful  to  meet,  we  would  welcome  the  opportunity  to  
discuss  these  issues  with  you  in  person  at  your  convenience.  Meanwhile,  I  hope  you  will  be  able  to  
consider  our  suggestions,  and  confirm  your  support  for  our  proposed  approach.          
Yours  sincerely  
Clive  Bates  
Former  Director  
Action  on  Smoking  &  Health  UK  (1997-­‐2003)  
 
Professor  Martin  Jarvis  
Emeritus  Professor  of  Health    Psychology  
Department  of  Epidemiology  &  Public  Health  
University  College  London,  UK  
 
Jacques  Le  Houezec,  PhD    
Consultant  in  Public  Health,  Tobacco  
dependence,  France    
 
Professor  Karl  Olov  Fagerström  PhD  
Emeritus  Professor  of  Psychology    
President  Fagerström  Consulting  AB  
 
Professor  Dr  Michael  Kunze  
Head  of  the  Institute  for  Social  Medicine  
Medical  University  of  Vienna  
 
 
 
Karl  Erik  Lund  PhD  
Research  Director  
Norwegian  Institute  for  Alcohol  and  Drug  
Research,  Oslo  Norway  
 
Dr  Lars  Ramström  
Director  Institute  for  Tobacco  Studies  
Stockholm  Sweden  
 
 
 
Professor  Tony  Axell  
Emeritus  Professor  Geriatric  Dentistry  
Consultant  in  Oral  Medicine  
 
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Notes  
                                                                                                                       
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 European  Commission,  Special  Eurobarometer  385,  Attitudes  of  European  Citizens  to  Tobacco,    March  2012    
 Phillips  CV,  Rabiu  D,  Rodu  B.  Calculating  the  comparative  mortality  risk  from  smokeless  tobacco  versus  
smoking.  
Am  J  Epidemiol  
2006;  163:  S189.
 
 WHO  /  International  Agency  for  Research  on  Cancer:    Cancer  mortality  database.    The  most  recent  figures  for  
Denmark  are  2006,  but  these  trends  change  slowly  as  they  represent  years  of  accumulated  smoking.    Lung  
cancer  also  has  poor  survival  rates  so  difference  are  unlikely  to  be  due  to  difference  in  treatment.  Lung  
cancer  is  a  good  marker  for  all  smoking  related  diseases  as  it  is  mostly  (c.  85-­‐90%)  attributable  to  smoking        
   
Opinion  of  the  Danish  Parliament  on  the  Commission  proposal  for  revision  of  the  Tobacco  Products  Directive  
-­‐  COM(2012)  788  [link]  
    WHO  study  group  on  tobacco  product  regulation  (2009).  Report  on  The  Scientific  Basis  Of  Tobacco  Product  
Regulation:  third  report  of  a  WHO  study  group.  WHO  technical  report  series;  no.  955.  WHO,  Geneva.  [Link]  
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